With the removal of cisapride from the market this past June, too many
questions have been left unanswered about the long term effects of medications which are
given to treat nausea and reflux. This questionnaire attempts to obtain those answers, your
participation is vital. Some
webhost (AOL) providers are not able to transmit this form, so after you have completed
the form, Print it out and mail it to:

Below is a list of symptoms
reported as adverse reactions to these medications. You are not expected
to understand all these terms. If you do not understand a term, pass it, because we have
included many lay terms which may describe those medical conditions which you may not
understand. Simply fill in the dates of all the symptoms or conditions which you or your
loved one has experienced anytime after being treated with metoclopramide
or propulsid. If a condition was experienced prior to treatment with the medication(s)
and did not worsen the pre-existing condition, leave it blank.

For new symptoms appearing after a medication was initiated give
the month and year (mm/yy) the symptom began and if it resolved, put the date it resolved.

If a symptom became obviously worse after beginning
medication, check the appropriate box(s) under the medication in which the symptom
worsened.

Date Began (or diagnosed)

Date
Resolved

Symptom
Worsened After
metoclopramide /
cisapride

insomnia

metoclopramide / propulsid

ADHD

metoclopramide / propulsid

"acting out"

metoclopramide / propulsid

mania

metoclopramide / propulsid

hyperactivity

metoclopramide / propulsid

anxiety/nervousness

metoclopramide / propulsid

autism

metoclopramide / propulsid

hallucinations

metoclopramide / propulsid

hypotonia

metoclopramide / propulsid

hypertonia

metoclopramide / propulsid

muscle cramps

metoclopramide / propulsid

muscle spasms

metoclopramide / propulsid

muscle weakness

metoclopramide / propulsid

muscle rigidity (stiffness)

metoclopramide / propulsid

chronic stiff neck

metoclopramide / propulsid

posturing

metoclopramide / propulsid

abnormal facial movements

metoclopramide / propulsid

abnormal tongue movements

metoclopramide / propulsid

torticollis

metoclopramide / propulsid

convulsions

metoclopramide / propulsid

abnormal (EEG) electoencephelogram

metoclopramide / propulsid

seizures

metoclopramide / propulsid

epilepsy

metoclopramide / propulsid

shivering

metoclopramide / propulsid

tremors

metoclopramide / propulsid

tics

metoclopramide / propulsid

Tourette Syndrome

metoclopramide / propulsid

Parkinson's

metoclopramide / propulsid

jerky movements

metoclopramide / propulsid

fevers of unknown (daily fevers) origin

metoclopramide / propulsid

high fever

metoclopramide / propulsid

brain atrophy

metoclopramide / propulsid

abnormal MRI

metoclopramide / propulsid

unknown neurological disorder

metoclopramide / propulsid

Neuroleptic Malignant Syndrome

metoclopramide / propulsid

Tardive Dyskinesia

metoclopramide / propulsid

extrapyramidal symptoms

metoclopramide / propulsid

Dystonic Reaction

metoclopramide / propulsid

Autoanomic nervous system imbalance

metoclopramide / propulsid

speech disorder

metoclopramide / propulsid

gait abnormal

metoclopramide / propulsid

movement disorder

metoclopramide / propulsid

palsy

metoclopramide / propulsid

paralysis

metoclopramide / propulsid

tinnitus

metoclopramide / propulsid

ringing in the ears

metoclopramide / propulsid

oculogyric crisus

metoclopramide / propulsid

eye rolling

metoclopramide / propulsid

abnormal eye movements

metoclopramide / propulsid

eyelid retraction or blinking

metoclopramide / propulsid

vision abnormal

metoclopramide / propulsid

transient blindness

metoclopramide / propulsid

aggression

metoclopramide / propulsid

irritability

metoclopramide / propulsid

depression

metoclopramide / propulsid

suicide attempt

anhedonia

metoclopramide / propulsid

amnesia

metoclopramide / propulsid

fatigue

metoclopramide / propulsid

lethargy

metoclopramide / propulsid

somnolonce

metoclopramide / propulsid

confusion

metoclopramide / propulsid

depressed level of consciousness

metoclopramide / propulsid

loss of consciousness

metoclopramide / propulsid

psychotic disorder

metoclopramide / propulsid

increased sweating

metoclopramide / propulsid

headache

metoclopramide / propulsid

migraine

metoclopramide / propulsid

dizziness / vertigo

metoclopramide / propulsid

salivary hypersecretion

metoclopramide / propulsid

choking

metoclopramide / propulsid

eating/feeding problem

metoclopramide / propulsid

apnea (including sleep apnea)

metoclopramide / propulsid

asthma

metoclopramide / propulsid

grunting

metoclopramide / propulsid

pulmonay distress

metoclopramide / propulsid

oxygen dependent

metoclopramide / propulsid

respiratory failure

metoclopramide / propulsid

respiratory rate increased

metoclopramide / propulsid

respiratory disorder

metoclopramide / propulsid

pulmonary congestion

metoclopramide / propulsid

pulmonary edema

metoclopramide / propulsid

pulmonary hypertention

metoclopramide / propulsid

pleural effusion

metoclopramide / propulsid

laryngitis

metoclopramide / propulsid

laryngeo spasm

metoclopramide / propulsid

bronchospasm

metoclopramide / propulsid

bronchitis

metoclopramide / propulsid

nasopharyngitis

metoclopramide / propulsid

croup

metoclopramide / propulsid

stridor

metoclopramide / propulsid

esophogeal spasm

metoclopramide / propulsid

cyanosis

metoclopramide / propulsid

flushing

metoclopramide / propulsid

hypoxia

metoclopramide / propulsid

obstructive airway
disease

metoclopramide / propulsid

dyspnea

metoclopramide / propulsid

shortness of breath

metoclopramide / propulsid

ventricular hypertrophy

metoclopramide / propulsid

valvular heart disease

metoclopramide / propulsid

cardiomyopathy

metoclopramide / propulsid

cardiomegaly

metoclopramide / propulsid

bradycardia

metoclopramide / propulsid

tachycardia

metoclopramide / propulsid

increased heart rate

metoclopramide / propulsid

decreased heart rate

metoclopramide / propulsid

enlarged heart

metoclopramide / propulsid

heart failure

metoclopramide / propulsid

cardiac arrest

metoclopramide / propulsid

cardiac arrhythmias

metoclopramide / propulsid

Long QT Syndrome

metoclopramide / propulsid

myoglobinemia

metoclopramide / propulsid

myglobinuria

metoclopramide / propulsid

urine discoloration

metoclopramide / propulsid

urinary frequency

metoclopramide / propulsid

urinary tract infection

metoclopramide / propulsid

urinary incontinence

metoclopramide / propulsid

urinary retention

metoclopramide / propulsid

abnormal urinalysis

metoclopramide / propulsid

decreased urine output

metoclopramide / propulsid

blood in urine

metoclopramide / propulsid

blood urea increased

metoclopramide / propulsid

hydronephrosis

metoclopramide / propulsid

pyelonephritis

metoclopramide / propulsid

nephritis

metoclopramide / propulsid

nephrotic syndrome

metoclopramide / propulsid

blood creatinine increased

metoclopramide / propulsid

blood creatine phosphokinase increased

metoclopramide / propulsid

adrenal insufficiency

metoclopramide / propulsid

renal failure

metoclopramide / propulsid

renal impairment

metoclopramide / propulsid

renal tubular acidosis

metoclopramide / propulsid

renal disorder

metoclopramide / propulsid

hypokalemia

metoclopramide / propulsid

low blood potassium

metoclopramide / propulsid

elevated blood potassium

metoclopramide / propulsid

hypoglycemia

metoclopramide / propulsid

hyponatremia

metoclopramide / propulsid

low blood sodium

metoclopramide / propulsid

high blood sodium

metoclopramide / propulsid

gall bladder disorder

metoclopramide / propulsid

decreased resistance to infection

metoclopramide / propulsid

sepsis

metoclopramide / propulsid

blood infection

metoclopramide / propulsid

pancytopenia

metoclopramide / propulsid

haematoma

metoclopramide / propulsid

hypogammaglobulinemia

metoclopramide / propulsid

thrombocytosis

metoclopramide / propulsid

thromopenia

metoclopramide / propulsid

increased platlets

metoclopramide / propulsid

decreased platlets

metoclopramide / propulsid

increased white blood cells

metoclopramide / propulsid

decreased white blood
cells

metoclopramide / propulsid

leukocytosis

metoclopramide / propulsid

leukopenia

metoclopramide / propulsid

enterocolitis

metoclopramide / propulsid

gastroenteritis

metoclopramide / propulsid

colitis

metoclopramide / propulsid

abdominal distention

metoclopramide / propulsid

constipation

metoclopramide / propulsid

ileus

metoclopramide / propulsid

chronic diarrhea

metoclopramide / propulsid

diarrhea

metoclopramide / propulsid

intestinal psuedo-obstruction

metoclopramide / propulsid

intestinal motility disorder

metoclopramide / propulsid

inflammatory bowel disease

metoclopramide / propulsid

gastro-intestinal ulcer

metoclopramide / propulsid

gastritis

metoclopramide / propulsid

malaena

metoclopramide / propulsid

intestinal bleeding

metoclopramide / propulsid

Steven Johnson Syndrome

metoclopramide / propulsid

oral/skin blisters

metoclopramide / propulsid

dermatitis

metoclopramide / propulsid

Epidermal Necrolysis

metoclopramide / propulsid

skin lesions (burnlike)

metoclopramide / propulsid

pregnancy loss

death

Additional
Comments/Symptoms

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